We have come to the point where it is time to start talking about 'The Fitting Game' . (This is a term that I picked up from Fritz Perls, the main founder of Gestalt Therapy.)
The concept of The Fitting Game can also be applied to Psychoanalysis, to Adlerian Psychology, to Object Relations, and to Transactional Analysis. Or all of them put together in DGB Transference-Lifestyle Analysis.
Let us imagine two different clusters of 'points on a graph'.
The first cluster of points occurs in 'early childhood', let us say arbitrarily for the time being up until the age of about 7 years old.
The second cluster of points occurs in 'adulthood'.
What we are going to do here is to 'connect these two clusters or sets of points with lines'.
Now for our purpose here, we are going to define 'narcissism' as either 'self-esteem', 'the lack of self-esteem', and/or 'the (often obsessive-compulsive) striving for self-esteem.
Thus, for our purpose here, an 'ego traumacy' can also be called a 'narcissistic traumacy' -- or worded otherwise, a 'traumacy in self-esteem'.
This brings us to one of the first paradoxes in the human personality -- a paradox that Alfred Adler mainly figured out, Carl Jung mainly figured out, Fritz Perls mainly figured out, Eric Berne mainly figured out -- but it gave Sigmund Freud a lot of trouble. The closest Sigmund Freud came to figuring this 'transference paradox' out was in 'Beyond The Pleasure Principle' where he started talking about 'The Mastery Compulsion'. But then Freud left the idea of the mastery compulsion -- which perhaps he deemed to be too close to Adler's ideas of 'inferiority feeling' and 'superiority striving' -- and Freud went on to create the dualism of the 'life and death instinct' competing against each other. And the rest was history.
If you change the ideas of 'life and death instinct' to 'life and death forces', then there is something to work with here. But that is a topic for a different day in a different context.
Relative to the idea of 'transference' and 'transference complex' and 'transference neurosis' and 'transference obsessive-compulsion', Freud was basically right on the money when he started talking about the mastery compulsion before -- like the Seduction Theory -- he abandoned it.
Many schools of psychology and psychotherapy have made a very good living off of the ideas that Freud abandoned.
Indeed, we could talk about -- and will talk about right now -- Freud's own 'seduction-abandonment transference-lifestyle complex' which very much affected the evolution and history of Psychoanalysis, Freud's 'counter-transferences' with his patients, Freud's counter-transferences with his own Psychoanalytic, Psychiatric, and Medical colleagues, and undoubtedly his relationship with his wife. That is the 'adult cluster of points' that we were talking about above.
Now let us turn to the childhood 'cluster of points'.
And this is where we have to start to step outside 'the assumptive Classical Psychoanalytic Box'.
Because if we all follow Classical Psychoanalytic thinking any further, then we will be no better than thousands of 'lemmings', each of which follows their 'esteemed leader' over the 'assumptive cliff'. Bad move!
Firstly, Classical Psychoanalysis does not link 'transference' and 'childhood memories'. Bad move! Bad assumption! Because this was the link on which all three ideas were born!: 1. childhood memories; 2. 'transference'; and 3. Psychoanalysis.
Let us go back to the first case of Psychoanalysis: Anna O.
Before we do, let me distinguish the difference between an 'encounter and/or memory' transference complex, and a 'relationship transference complex'.
A. Here is an example of an 'encounter-memory' transference complex: 1. Anna O. (generally viewed as the first 'Psychoanalytic patient') sees a dog drinking from her cup or a bowl when she is a young girl; 2. supposedly she 'represses' (or suppresses) the memory; 3. she no longer will drink and must get all her liquids from fruits; 4. Breuer puts her into a 'hypnotic trance' or just lets her indulge in 'the talking cure' until she 'recovers' the dog memory; 5. she goes through a huge negative emotional reaction (abreaction, catharsis); 6. for the first time since the memory, she starts to drink again. 'Psychoanalysis' is essentially born -- even though it isn't named this yet. And this case happened before Freud entered the picture. Charcot and Janet were doing similar work in France.
B. Now, here is an example of a 'relationship transference complex' -- again involving Anna O. 'undiagnosed' as such by anyone other than yours truly in Hegel's Hotel. Anna O. had a very sick father -- perhaps tuberculosis or something of that order -- and consequently, Anna O. was constantly nursing over him, even as, and/or starting as, a young adult woman (which precipitated her arrival into Dr. Breuer's new 'form of therapy' which had yet to be called 'Psychoanalysis'. The Anna O. case took place in the early 1880s and the term 'Psycho-analysis' wasn't created til 'Studies on Hysteria', 1893-1895, at which point Freud had already seen how Charcot and Janet worked in Paris, as well as hearing Breuer's stories about his Anna O. case).
So in effect, Anna O. had no adult life of her own other than nursing over her sick father. This undoubtedly created an internal conflict inside her. Other young women were dating and getting married -- and here Anna O. was -- essentially locked in a 'master-slave' relationship (to use one of Hegel's most famous 'bi-polar concepts' and 'interpretive dialectical analyses') with her father where her father was essentially 'the master' controlling her daughter's 'every move' which essentially turned his daughter into a 'slave' constantly attending to her father's every need. (One wonders where Anna O.s seemingly continually absent mother was during this whole process?)
So, Anna O. starts demonstrating these 'crazy hysterical symptoms' and 'psychotic hallucinations'...and some modern day theorists have 'historically diagnosed' Anna O. with having some sort of a 'brain disorder', perhaps a 'tumor' or 'epilepsy' or 'schizophrenia'. Most modern day theorists and therapists to my knowedge don't use the 'diagnostic category' of 'hysteria' any more although to be sure 'psychological symptoms' can be turned into 'bodily symptoms' although probably not usually in the 'bizarre fashion' that some of Freud's and Charcot's and Breuer's earliest patients did. There remains significant controversy over the issue of whether or not the diagnostic category of 'hysteria' is a legitimate 'psychological and/or medical category or not' -- or whether it is, or was, a 'symptom in itself' of a 'masculine dominated society where some women were in effect 'stereotyped' and 'classified as hysterics' when they went to rather bizarre extremes to demonstrate in effect that they didn't like their 'feminine slave' role in Victorian society. (Speaking from personal experience, -- and speaking metaphorically -- I have had more than a couple of girlfriends who have 'gone hysterical' on me. But 'dialectically speaking', one has to look at the whole 'context' of the relationship the 'supposedly hysterical person' is coming from, which, yes, means my role in these relationships, as well as, both then and now, the woman's 'serial behavior background' which is the key to understanding the woman's particular 'transference-lifestyle complex and neurosis' -- as well as the man's 'serial behavior background' and his particular 'transference-lifestyle complex-neurosis.
It is from here that you can start to determine the particular types of 'transference-lifestyle games' that adults (and children) can play with each other. (See Eric Berne, 'Games People Play', and 'Transactional Analysis').
Back to Anna O. Enter Dr. Breuer. At this point, Anna O. did something very, very sneaky -- she may not have even known she was doing it. Or maybe she did. She 'turned the tables' on Dr. Breuer. She instigated what might be called a 'reverse father-transference relationship'. In effect, she took over the 'role model' of her sick father and became 'the sick daughter'. And once she started to take over the 'sick role', she started to see that she had 'power' over Dr. Breuer. And she liked that. She had become the 'master'. And Dr. Breuer had become the 'slave'. For every new 'hysterical symtom' that Anna O. created, she could enjoy the experience of making Dr. Breuer 'jump through a new hoop'. For he would have to 'track down the etiology of the new hysterical symptom in order to help Anna O. get rid of it'. But here is where the 'transference relationship game' just got started. For every 'hysterical symptom' that Breuer helped Anna O. 'remove', she created a bunch more. It became a 'never ending therapeutic process'. Pretty soon, Dr. Breuer was starting to get exhausted from all the 'hypnotic work' he had to do with Anna O to keep trying to get rid of every new hysterical symptom that she created. While subconsciously, let me suggest that Anna O. was getting her 'transference fix' out of this whole process. This is what I call 'the mastery compulsion'. In her relationship with her father, Anna O. played the 'slave' and her father played the 'sick master'. Now, with Dr. Breuer, the whole 'father transference relationship' was reversed. Anna O. played the 'sick puppeteer'. And Breuer played 'Pinnochio'. Anna O. subconsciously or consciously, according to my 'transference-interpretation', liked playing the role of her 'sick father' much, much better than she liked playing the role of the 'slave-therapist'. Introduce a 'romantic-erotic' component to the 'transference game' and now she had almost everything she wanted. It was a lot more fun being with Dr. Breuer than it was being with her father. (Even if there was guilt created by 'being away from her father'. But she could rationalize and justify this guilt because she was 'sick'. And have fun with Dr. Breuer in the process. Dr. Breuer was 'working like a mad man to help clear away all her symptoms'. Poor Dr. Breuer -- or maybe not so poor -- had hardly any time and energy left over for his wife and family. The icing on the cake came when Anna O. introduced her 'pregnancy and baby fantasy'.
Please excuse my sometimes morbid sense of humor because I find this 'hysterically funny':
'Dr. Breuer', I can imagine Anna O. saying in some fashion or another, 'I'm pregnant. I'm having your baby.' It has been a while since I have read this whole case but I think there may have even been some 'hysterical-fantasized birth contractions' involved in one or more of the therapeutic sessions. I will include an excerpt of the case history after this essay is over.
Well, you can imagine the look of panic on Dr. Breuer's face. Who knows? Maybe there was some 'erotic hanky panky' and some 'therapeutic ethical violations' that we don't know about that made this whole development more than only fantasy. Sometimes -- oftentimes -- memories and fantasies get objectively and/or subjectively intertwined with each other making this more than an Aristotelean 'either/or' situation. Either 'reality'. Or 'fantasy'. Maybe it was a combination of both. Probably it was a combination of both but we do not know some 115 years later to what extent. Maybe there was a 'therapeutic cover-up or white-washing' of the case. We don't know.
What we do know is that Breuer 'exited stage left'. Perhaps in 'mid birth contraction'. Or perhaps he finished the session. But one way or the other, he decided that he needed to see more of his wife and family. And more tragically, to my knowledge, Anna O. spent part or most of the rest of her life in and out of a 'sanatorium'. But she was a smart woman who became a social worker too. Let me re-copy two different renditions of the whole case for you to read, interpret, and judge yourself.
We have covered enough for this morning.
-- dgb, Dec. 30th, 2009.
-- David Gordon Bain,
-- Dialectic Gap-Bridging Negotiations...
-- Are Still In Process...
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Sigmund Freud on Anna O. Case ]
Dr. Breuer's patient was a girl of twenty-one, of high intellectual gifts. Her illness lasted for over two years, and in the course of it she developed a series of physical and psychological disturbances which decidedly deserved to be taken seriously. She suffered from a rigid paralysis, accompanied by loss of sensation, of both extremities on the right side of her body; and the same trouble from time to time affected her on her left side. Her eye movements were disturbed and her power of vision was subject to numerous restrictions. She had difficulties over the posture of
Bertha Pappenheim
alias Anna O. the famous patient who inspired the psychoanalytic talking cure while in treatment with Dr. Breuer
her head; she had a severe nervous cough. She had an aversion to taking nourishment, and on one occasion she was for several weeks unable to drink in spite of a tormenting thirst. Her powers of speech were reduced, even to the point of her being unable to speak or understand her native language. Finally, she was subject to conditions of 'absence',(1) of confusion, of delirium, and of alteration of her whole personality, to which we shall have presently to turn our attention.
When you hear such an enumeration of symptoms, you will be inclined to think it safe to assume, even though you are not doctors, that what we have before us is a severe illness, probably affecting the brain, that it offers small prospect of recovery and will probably lead to the patient's early decease. You must be prepared to learn from the doctors, however, that, in a number of cases which display severe symptoms such as these, it is justifiable to take a different and a far more favourable view. If a picture of this kind is presented by a young patient of the female sex, whose vital internal organs (heart, kidneys, etc.) are shown on objective examination to be normal, but who has been subjected to violent emotional shocks - if, moreover, her various symptoms differ in certain matters of detail from what would have been expected - then doctors are not inclined to take the case too seriously. They decide that what they have before them is not an organic disease of the brain, but the enigmatic condition which, from the time of ancient Greek medicine, has been known as 'hysteria' and which has the power of producing illusory pictures of a whole number of serious diseases. They consider that there is then no risk to life but that a return to health - even a complete one - is probable. It is not always quite easy to distinguish a hysteria like this from a severe organic illness. There is no need for us to know, however, how a differential diagnosis of that kind is made; it will suffice to have an assurance that the case of Breuer's patient was precisely of a kind in which no competent physician could fail to make a diagnosis of hysteria. And here we may quote from the report of the patient's illness the further fact that it made its appearance at a time when she was nursing her father, of whom she was devotedly fond, through the grave illness which led to his death, and that, as a result of her own illness, she was obliged to give up nursing him.
[...] Dr. Breuer's attitude towards his patient deserved no such reproach. He gave her both sympathy and interest, even though, to begin with, he did not know how to help her. It seems likely that she herself made his task easier by the admirable qualities of intellect and character to which he has testified in her case history. Soon, moreover, his benevolent scrutiny showed him the means of bringing her a first instalment of help.
It was observed that, while the patient was in her states of 'absence (altered personality accompanied by confusion), she was in the habit of muttering a few words to herself which seemed as though they arose from some train of thought that was occupying her mind. The doctor, after getting a report of these words, used to put her into a kind of hypnosis and then repeat them to her so as to induce her to use them as a starting point. The patient complied with the plan, and in this way reproduced in his presence the mental creations which had been occupying her mind during the 'absences' and which had betrayed their existence by the fragmentary words which she had uttered. They were profoundly melancholy phantasies - 'day dreams' we should call them - sometimes characterized by poetic beauty, and their starting-point was as a rule the position of a girl at her father's sick-bed. When she had related a number of these phantasies, she was as if set free, and she was brought back to normal mental life. The improvement in her condition, which would last for several hours, would be succeeded next day by a further attack of 'absence'; and this in turn would be removed in the same way by getting her to put into words her freshly constructed phantasies. It was impossible to escape the conclusion that the alteration in her mental state which was expressed in the 'absences' was a result of the stimulus proceeding from these highly emotional phantasies. The patient herself, who, strange to say, could at this time only speak and understand English, christened this novel kind of treatment the 'talking cure'(2) or used to refer to it jokingly as 'chimney sweeping'.(2)
It soon emerged, as though by chance, that this process of sweeping the mind clean could accomplish more than the merely temporary relief of her ever-recurring mental confusion. It was actually possible to bring about the disappearance of the painful symptoms of her illness, if she could be brought to remember under hypnosis, with an accompanying expression of affect, on what occasion and in what connection the symptom had first appeared. 'It was in the summer during a period of extreme heat, and the patient was suffering very badly from thirst; for, without being able to account for it in any way, she suddenly found it impossible to drink. She would take up the glass of water that she longed for, but as soon as it touched her lips she would push it away like someone suffering from hydrophobia. As she did this, she was obviously in an absence for a couple of seconds. She lived only on fruit, such as melons, etc., so as to lessen her tormenting thirst. This had lasted for some six weeks, when one day during hypnosis she grumbled about her English "lady-companion", whom she did not care for, and went on to describe, with every sign of disgust, how she had once gone into this lady's room and how her little dog - horrid creature! - had drunk out of a glass there. The patient had said nothing, as she had wanted to be polite. After giving further energetic expression to the anger she had held back, she asked for something to drink, drank a large quantity of water without any difficulty, and awoke from her hypnosis with the glass at her lips; and thereupon the disturbance vanished, never to return.'(3)
[...] No doubt you will now ask me for some further instances of the causation of hysterical symptoms besides the one I have already given you of a fear of water produced by disgust at a dog drinking out of a glass. But if I am to keep to my programme I shall have to restrict myself to very few examples. In regard to the patient's disturbances of vision, for instance, Breuer describes how they were traced back to occasions such as one on which, 'when she was sitting by her father's bedside with tears in her eyes, he suddenly asked her what time it was. She could not see clearly; she made a great effort, and brought her watch near to her eyes. The face of the watch now seemed very big - thus accounting for her macropsia and convergent squint. Or again, she tried hard to suppress her tears so that the sick man should not see them.'¥ Moreover, all of the pathogenic impressions came from the period during which she was helping to nurse her sick father. 'She once woke up during the night in great anxiety about the patient, who was in a high fever; and she was under the strain of expecting the arrival of a surgeon from Vienna who was to operate. Her mother had gone away for a short time and Anna was sitting at the bedside with her right arm over the back of her chair. She fell into a waking dream and saw a black snake coming towards the sick man from the wall to bite him. (It is most likely that there were in fact snakes in the field behind the house and that these had previously given the girl a fright; they would thus have provided the material for her hallucination.) She tried to keep the snake off, but it was as though she was paralysed. Her right arm, over the back of the chair, had gone to sleep, and had become anaesthetic and paretic; and when she looked at it the fingers turned into little snakes with death's heads (the nails). (It seems probable that she had tried to use her paralysed right hand to drive off the snake and that its anaesthesia and paralysis has consequently become associated with the hallucination of the snake.) When the snake vanished, in her terror she tried to pray. But language failed her: she could find no tongue in which to speak, till at last she thought of some children's verses in English and then found herself able to think and pray in that language.'(4) When the patient had recollected this scene in hypnosis, the rigid paralysis of her left arm, which had persisted since the beginning of her illness, disappeared, and the treatment was brought to an end.
When, some years later, I began to employ Breuer's method of examination and treatment on patients of my own, my experiences agreed entirely with his. A lady, aged about forty, suffered from a tic consisting of a peculiar 'clacking' sound which she produced whenever she was excited, or sometimes for no visible reason. It had its origin in two experiences, whose common element lay in the fact that at the moment of their occurrence she had formed a determination not to make any noise, and in the fact that on both these occasions a kind of counter-will led her to break the silence with this same sound. On the first of these occasions one of her children had been ill, and, when she had at last with great difficulty succeeded in getting it off to sleep, she had said to herself that she must keep absolutely still so as not to wake it. On the other occasion, while she was driving with her two children in a thunderstorm, the horses had bolted and she had carefully tried to avoid making any noise for fear of frightening them even more.(5) I give you this one example out of a number of others which are reported in the Studies on Hysteria.(6)
[...] Ladies and Gentlemen, if I may be allowed to generalize - which is unavoidable in so condensed an account as this - I should like to formulate what we have learned so far as follows: our hysterical patients suffer from reminiscences. Their symptoms are residues and mnemic symbols of particular (traumatic) experiences.
Notes:
1. The French term.
2. In English in the original.
3. Studies on Hysteria.
4. Studies on Hysteria.
5. Studies on Hysteria.
6. Extracts from that volume, together with some later writings of mine on hysteria, are now to be had in an English translation prepared by Dr. A. A. Brill of New York.
From Sigmund Freud: Five Lectures on Psychoanalysis.
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Anna O.
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Anna O. was the pseudonym of a patient of Josef Breuer, who published her case study in his book Studies on Hysteria, written in collaboration with Sigmund Freud. Note: This article is concerned with Bertha Pappenheim as the patient Anna O. Her youth and her life from the time her treatment ceased in 1882 until her death, including her extensive literary and social work, is covered in the Wikipedia entry Bertha Pappenheim.
Anna O was, in fact, Bertha Pappenheim (1859-1936), an Austrian-Jewish feminist and the founder of the Jüdischer Frauenbund (League of Jewish Women), who was treated by Breuer for severe cough, paralysis of the extremities on the right side of her body, and disturbances of vision, hearing, and speech, as well as hallucination and loss of consciousness. She was diagnosed with hysteria. Freud implies that her illness was a result of the grief felt over her father's real and physical illness that later led to his death[1].
Her treatment is regarded as marking the beginning of psychoanalysis. Breuer observed that whilst she experienced 'absences' (a change of personality accompanied by confusion), she would mutter words or phrases to herself. In inducing her to a state of hypnosis, Breuer found that these words were "profoundly melancholy phantasies...sometimes characterized by poetic beauty". Free Association came into being after Anna/Bertha decided (with Breuer's input) to end her hypnosis sessions and merely talk to Breuer, saying anything that came into her mind. She called this method of communication "chimney sweeping", and this served as the beginning of free association.
Anna's/Bertha's case also shed light for the first time on the phenomenon called transference, where the patient's feelings toward a significant figure in his/her life are redirected onto the therapist. By transference, Anna imagined to be pregnant with the doctor's baby. She experienced nausea and all the pregnancy symptoms. After this incident, Breuer stopped treating her.
Historical records since showed that when Breuer stopped treating Anna O. she was not becoming better but progressively worse[2]. In fact she was ultimately institutionalised: "Breuer told Freud that she was deranged; he hoped she would die to end her suffering"[3].
She later recovered over time and led a productive life. The West German government issued a postage stamp in honour of her contributions to the field of social work[4].
According to current research, "examination of the neurological details suggests that Anna suffered from complex partial seizures exacerbated by drug dependence."[5] In other words, her illness was not, as Freud suggested, psychological, but neurological. Many believe that Freud misdiagnosed her, and she in fact suffered from temporal lobe epilepsy, and many of her symptoms, including imagined smells, are common symptoms of types of epilepsy.[6]
German postage stamp (1954) in the series Benefactors of MankindContents [hide]
1 Illness
2 Death of her father
3 Bellevue Sanatorium
4 Anna O.
5 Sources
6 Treatment
7 Conclusion of treatment
8 Success of treatment
9 See also
10 Further reading
11 References
[edit] Illness
Bertha’s father fell seriously ill of pleurisy in summer 1880 during a family holiday in Ischl. This event was a turning point in her life. While sitting up at night at his sickbed she was suddenly tormented by hallucinations and a state of anxiety.[7] Her illness later developed a wide spectrum of symptoms:
Language disorders (aphasia): On some occasions she could not speak at all, sometimes she spoke only English, or only French, or Italian. She could however always understand German. The periods of aphasia could last for days, and sometimes varied with the time of day.
Neuralgia: She suffered from facial pain which was treated with morphine and chloral and led to addiction. The pain was so severe that surgical severance of the trigeminus nerve was considered.
Paralysis (paresis): Signs of paralysis and numbness occurred in her limbs, primarily on only one side. Although she was right-handed, she had to learn to write with her left hand because of this condition.
Visual disorders: She had temporary motor disturbances in her eyes. She perceived objects as being greatly enlarged and she squinted.
Mood changes: Over long periods she had daily swings between conditions of anxiety and depression, followed by relaxed states.
Amnesia: When she was in one of these states she could not remember events or any of her own actions which took place when she was in the other state.
Eating disorders: In crisis situations she refused to eat. During one hot summer she rejected liquids for weeks and lived only on fruit.
At first the family did not react to these symptoms, but in November a friend of the family, the physician Josef Breuer, began to treat her. He encouraged her, sometimes under light hypnosis, to narrate stories, which led to partial improvement of the clinical picture, although her overall condition continued to deteriorate. Starting on 11 December Bertha Pappenheim was bedridden for several months.
[edit] Death of her father
Bertha Pappenheim‘s father died on 5 April 1881. As a result she became fully rigid and did not eat for days. Her symptoms continued to get worse and on 7 June she was admitted against her will to the Inzersdorf sanatorium, where she remained until November. After returning she continued to be treated by Breuer. She returned to this sanatorium several times over the course of the following years (sometimes at her own wish).
According to Breuer, the slow and laborious progress of her “remembering work” in which she recalled individual symptoms after they had occurred, thus “dissolving” them, came to a conclusion on 7 June 1882 after she had reconstructed the first night of hallucinations in Ischl. “She has fully recovered since that time” were the words with which Breuer concluded his case report.[8]
[edit] Bellevue Sanatorium
Already on 12 July 1882 Breuer referred Bertha Pappenheim to the private Bellevue Clinic in Kreuzlingen on Lake Constance, which was headed by Robert Binswanger. After treatment in Bellevue she was no longer personally treated by Breuer.
While in Kreuzlingen she visited her cousins Fritz Homburger and Anna Ettlinger in Karlsruhe. The latter was one of the founders of the Karlsruhe High School for Girls (Mädchengymnasium), which was also attended by the young Rahel Straus. Anna Ettlinger engaged in literary work. In an article which appeared in 1870 entitled "A Discussion of Women’s Rights" (Ein Gespräch über die Frauenfrage) she demanded equal education rights for women. She also gave private lessons, and organized "ladies’ literature courses".
Bertha Pappenheim during her stay at Bellevue Sanatorium in 1882Bertha Pappenheim read aloud to her some of the stories she had written, and her cousin, 14 years her senior, encouraged her to continue her literary activities.[9] During this visit toward the end of 1882 Bertha Pappenheim also participated in a training course for nurses which was offered by the Women’s Association of Baden (Badischer Frauenverein). The purpose of this training was to qualify young ladies to head nursing institutions. She could not finish the course before her visit came to an end.
On 29 October 1882 her condition improved and she was released from treatment in Kreuzlingen. In the following years, about which little is known, she lived a quiet life with her mother in Vienna. There is evidence of three stays at Inzersdorf during this time; her sickness was not conquered.
Despite her illness, Bertha Pappenheim was a strong personality. Breuer describes her as a women „of considerable intelligence, astonishingly astute reasoning and sharp-sighted intuition [...]”.[10]
[edit] Anna O.
Bertha Pappenheim became known to the general public under the pseudonym of Miss "Anna O.", a patient of Josef Breuer. Her case history was described in Studies on Hysteria (Studien über Hysterie) (1895), which Breuer published together with Sigmund Freud. She is presented as the first case in which it was possible to "thoroughly investigate" hysteria and cause its symptoms to disappear. Her statement that being able to verbalize her problem helped her to unburden herself is in accordance with the treatment later denoted in psychoanalysis as the "catharsis theory". Accordingly, Freud described her as the "actual founder of the psychoanalytic approach". Based on this case study the assertion that "those with hysteria suffer for the most part from their reminiscences", in other words from traumatic memories which can be "processed" by relating them, was formulated for the first time.[11]
Freud himself wrote:
Breuer’s findings are still today the foundation of psychoanalytic therapy. The statement that symptoms disappear with awareness of their unconscious preconditions has been confirmed by all subsequent research […].[12]
[edit] Sources
Aspects of the Anna O. case were first published by Freud and Breuer in 1893 as preliminary communications in two Viennese medical journals. The detailed case history appeared in 1895 in Studies on Hysteria.
The name Anna O. was constructed by shifting her initials "B.P." one letter back in the alphabet to "A.O."
When the first volume of Ernest Jones’ Freud biography appeared in 1953, in which the Anna O. of the studies was identified as being Bertha Pappenheim, her friends and admirers were outraged; they only knew her from her time in Frankfurt. One of the reasons for Dora Edinger's biography was to contrast her identification as being "mentally ill", which at the time was considered defamatory, with a depiction of Pappenheim as a philanthropist and advocate of womens’ rights.
Jones' portrayal contained further details, especially legends about the conclusion of Breuer’s treatment, but except for the information contained in the studies nothing was known about the further course of her illness. New facts only became known based on research by Henri Ellenberger and subsequently by Albrecht Hirschmüller, who were able to find Breuer’s case history of Pappenheim and other documents in the archives of the Bellevue Clinic in Kreuzlingen.[13]
Those of Freud’s letters to his fianceé Martha Bernays which have been published contain a few hints about the course of Pappenheim’s therapy and Freud’s relationship to Breuer, but until all of Freud’s letters are published there is room for all kinds of speculation.[14]
[edit] Treatment
Breuer began the therapy without a clear method or theoretical basis. The treatment of her symptoms ranged from feeding her when she rejected food to dosages of chloral when she was agitated.
He described his observations as follows:
She had two completely separate states of consciousness which alternated quite often and suddenly, and in the course of her illness became more and more distinct. In the one state she was sad and apprehensive, but relatively normal. In the other state she had hallucinations and "misbehaved", that is, she swore, threw pillows at people, […] etc.[15]
He noted that when in one conditions she could not remember events or situations that had occurred in the other condition. His conclusion:
It is difficult to avoid saying that she dissolved into two personalities, one of which was psychically normal and the other mentally ill.[16] Symptoms of this type are associated with the clinical picture of dissociative identity disorder; at the time the term "split personality" was used. In Breuer’s time the existence and frequency of such an illness was controversial, as it remains today. A first therapy approach was suggested by the observation that the patient calmed down and her speech disorder improved whenever she was asked to tell stories that had presumably arisen from her daydreams. About these daydreams Breuer remarked: "Although everyone thought she was present, she was living in a fantasy, but as she was always present when addressed, nobody suspected it.[17] He also encouraged and prompted her to calmly "reel off" these stories, for example by supplying a first sentence. The formula he used was always the same, "There was a boy…." At times Pappenheim could only express herself in English, but usually understood the German spoken around her. About her descriptions Breuer said, "The stories, always sad, were sometimes quite nice, similar to Andersen’s 'Picture Book Without Pictures'".[18]
The patient was aware of the relief that "rattling off" brought her , and she described the process using the terms "chimney-sweeping" and "talking cure". The latter formulation subsequently became part of psychoanalytic terminology.
Soon other levels of story telling came up which were combined with and penetrated each other:
Stories from a "private theater"
Hallucinatory experiences
Temporal relocation of episodes: during one phase her experience of the illness was shifted by one year
Episodes of occurrence of hysterical symptoms
Systematic remembering and "reeling off" the occasions when hysterical symptoms first occurred was developed by Breuer into a therapeutic method first applied to Pappenheim. To his surprise he noticed that a symptom disappeared after the first occurrence was remembered, or after the cause was "excavated".
Breuer described his final methodology as follows: In the morning he asked Pappenheim under light hypnosis about the occasions and circumstances under which a particular symptom occurred. When he saw her in the evening, these episodes—there were sometimes over 100—were systematically "reeled off" by Pappenheim in reverse temporal order. When she got to the first occurrence and thus to the "cause", the symptoms appeared in an intensified form and then disappeared "forever".
This therapy came to a conclusion when they had worked their way back to a "black snake" hallucination which Pappenheim experienced one night in Ischl when she was at her father's sickbed. Breuer describes this finish as follows:
In this way all the hysteria came to an end. The patient herself had made a firm resolution to finish the business on the anniversary of her transfer to the countryside. For that reason she pursued the "talking cure" with great energy and animation. On the final day she reproduced the anxiety hallucination which was the root of all her illness and in which she could only think and pray in English, helped along by rearranging the room to resemble her father's sickroom. Immediately thereafter she spoke German and was then free of all the innumerable individual disorders which she had formerly shown.[19]
[edit] Conclusion of treatment
A legend arose about the conclusion of Pappenheim‘s treatment by Josef Breuer. It was handed down in slightly different versions by various people; one version is contained in a letter from Freud to Stefan Zweig:
I was in a position to guess what really happened with Br’s patient long after we parted company when I recalled a communication from Br dating from the time before our joint work and relating to another context, and which he never repeated. That evening, after all her symptoms were overcome, he was again called to her, and found her confused and writhing with abdominal cramps. When asked what was the matter she responded, "Now the child I have from Dr. Br. is coming". At that moment he had in his hand the key which would open the way to the Mothers, but he dropped it. With all his intellectual talents he was devoid of anything Faustian. He took flight in conventional horror and passed on the patient to a colleague. She struggled for months in a sanatorium to regain her health./ I was so sure of my reconsruction that I published it somewhere. Br’s younger daughter (who was born shortly after the conclusion of that therapy, which is not irrelevant as to a meaningful connection) read my portrayal and asked her father about it (this was shortly before his death). He confirmed my analysis, which she later relayed to me.[20]
As nothing is known of such a publication by Freud, it is not clear where Breuer’s daughter could have read it. In the version by Ernest Jones, after his flight Breuer quickly goes on a second honeymoon to Vienna with his wife Mathilda, who actually conceives a child there—in contrast to the imaginary child of Bertha Pappenheim. There is no evidence for any of this, and most of it has been proved false. Breuer did not flee but rather referred his patient to Kreuzlingen. He did not go to Venice but with his family on a summer vacation to Gmunden, and he did not conceive a child (either in Venice or in Gmunden), since his youngest child—Dora Breuer—was born on 11 März 1882, three months before the alleged conception.
Freud’s purpose in describing the conclusion of treatment in a way that contradicts some of the verifiable facts is unclear. The assumption that he wanted to make himself the sole discoverer of psychoanalysis at Breuer’s expense is contradicted by the description of the discovery in Freud’s writings, in which he does not minimize Breuer’s role , but rather emphasizes it. Freud’s behavior is compared by some authors with his conduct in the so-called "cocaine affair". There, too, he gave false representations not only privately, but also several times in published form, without there being any advantage to offset the risk of lasting damage to his scientific reputation.
Breuer later described the therapy as "a trial by ordeal", probably in the sense of an examination. It claimed of him over 1,000 hours in the course of two years.
Success of treatment
After Breuer ceased treating her, both he and Freud continued to follow the course of Pappenheim‘s illness.[21] Among Freud‘s disciples the dubiousness of the assertion of “treatment success” was discussed. In a private seminar Carl Gustav Jung said in 1925:
So the famous first case he treated together with Breuer and which was vastly praised as an outstanding therapeutic success was nothing of the sort.[22]
And Charles Aldrich reports:
But in this famous case the patient was not healed. Freud told Jung that all her old symptoms returned after he had given up the case.[23]
Opponents of pyschoanalysis use this statement as an argument against this therapeutic approach.
How Pappenheim herself assessed the success of her treatment is not documented.[24] She never spoke about this episode of her life and vehemently opposed any attempts at psychoanalytic treatment of people in her care.[25]
Aspects of Bertha Pappenheim‘s biography(especially her role as Breuer’s patient) were treated in the film Freud by John Huston (along with elements of other early psychoanalytic case histories). The film is based on a screenplay by Jean-Paul Sartre, who however distanced himself from the film version.
